As noted in Chapter 2, trauma survivors—especially victims of interpersonal

violence—are prone to self-blame, guilt, shame, low self-esteem, overestimation of

danger, and other negative beliefs and perceptions. The rape victim may believe she
somehow “asked for it” or otherwise caused herself to be assaulted, and the
battered woman may assume that she deserved to be beaten. Individuals who have been
repeatedly exposed to situations in which they were helpless to escape or otherwise
reduce their trauma exposure often develop a sense of having little power to affect
future potentially negative events. Some survivors view their posttraumatic
symptoms as evidence of being defective or “crazy.” Victims of sexual trauma often
feel ashamed and isolated by their experiences.

In general, cognitive therapy of posttraumatic disturbance involves the guided

reconsideration of negative perceptions and beliefs about self, others, and the
environment that arose from the trauma. As these negative assumptions are
reevaluated, a more affirming and empowering model of self and others frequently
takes its place. At the same time, the client may develop a more detailed and
coherent understanding of the traumatic event, a process that is associated with
clinical improvement (Foa, Molnar, & Cashman, 1995).

COGNITIVE PROCESSING

In most cases, trauma-related cognitive disturbance is addressed through detailed

verbal exploration of the traumatic event and its surrounding circumstances. As the
client repeatedly describes the trauma in the context of treatment, he or she, in a
sense, relives the past while viewing it from the perspective of the present. By
verbally recounting the traumatic event, the client (often with the assistance of
the therapist) has the opportunity to “hear” the assumptions, beliefs, and
perceptions that were encoded at the time of the trauma, understand the reasons
they arose, and compare them with what he or she now knows. Together, the client
and therapist can then work to create a more accurate cognitive model of what
occurred.

This interactive process frequently fosters more positive self-perceptions as the

client comes to reinterpret former “bad” behaviors, deservingness of maltreatment,
and presumed inadequacies in a more accurate light. For example, the client who has
always interpreted her behavior just prior to a rape as “sluttish” or “asking for
it” may gain from the opportunity to relive and review what actually happened and
to see if her judgments about herself seem valid. Exploration of the events prior
to the rape may reveal that she was not behaving in a “seductive” manner, nor is
she likely to recall wanting to be abused or otherwise hurt. It is important to
acknowledge that such exploration typically does not suggest that this early
perception was “irrational,” but rather that it logically arose from the context of
the trauma.

A growing awareness of what one could reasonably have done at the time of the
trauma—that is, what one’s options actually were—can be antidotal to inappropriate
feelings of responsibility, self-blame, or self-criticism. For example, describing
memories of childhood abuse—while at the same time listening to them from the
perspective of an adult—may lead to the realization that one had few options other
than subservience or accommodation at the time of the abuse. The notion that “I
should have done something to stop it,” for example, might be countered by a
greater experiential understanding of the size and power differentials inherent in
an adult forcing his or her will (and body) on a 7-year-old child.
Finally, blaming or shaming statements made by an assailant may gradually lose
their power when examined in the context of a safe environment. Many victims of
interpersonal violence tend to internalize or otherwise accept rationalizations
used by the perpetrator at the time of the assault (Salter, 1995). These include
batterer statements that the victim deserved violence for failing to be a good
spouse, rapist statements that the victim was asking to be sexually assaulted, and
child abuser statements that physical abuse was merely appropriate punishment for
bad behavior. For example, a refugee may have partially accepted statements made by
his torturers that he was responsible for his family’s death by virtue of being a
“traitor,” when, in fact, (1) he did nothing to justify such horrible events, and
(2) the deaths were committed by the government, not by him. The childhood trauma
survivor may internalize more general perpetrator comments that he or she is bad,
fat, ugly, or worthless. As the client and therapist discuss the circumstances of
the event and consider perpetrator statements in the absence of danger or coercion,
the objective lack of support for these statements may become more apparent to the
client.

Because he or she is often more able to see these cognitive distortions than is the
client, the clinician may feel pressed to voice an opinion regarding the lack of
culpability of the victim or the obvious cruelty of the perpetrator. This is
understandable, and, in small doses, is usually appropriate. But such statements
should be presented as a form of “going on the record” regarding the therapist’s
clear understanding that the victim was, in fact, victimized. Rarely will such
statements, in and of themselves, actually change the client’s opinion. In fact,
clinical experience suggests that cognitive therapy is rarely helpful when the
clinician merely disagrees (or argues) with the client about his or her cognitions
or memories, or makes definitive statements about what reality actually is or was.
Rather, cognitive interventions are most effective when they provide opportunities
for the client to experience the original trauma-related thoughts and self-
perceptions (for example, feelings of responsibility and guilt when recalling being
beaten by a spouse), while at the same time considering a more contemporary and
logical perspective (for example, that the beatings were, ultimately, about the
spouse’s chronic anger, alcoholism, and feelings of inadequacy, and not due to the
client’s failure to wash the dishes or provide sex on demand).

As suggested by Resick and Schnicke (1992), the reworking of trauma-related

assumptions or perceptions is probably most effective when it occurs while the
client is actively remembering the trauma and reexperiencing the thoughts and
feelings he or she had at the time. In other words, merely discussing a traumatic
event without some level of emotional memory activation is less likely to allow the
client to change the cognitions related to the memory. In contrast, active recall
and description of a traumatic event probably trigger two parallel processes: (1)
observation of one’s own trauma-related attributions regarding the specifics of the
event, and (2) activation of the emotions associated with the event. The second
component of this response is covered in detail in the next chapter. However, it is
important to acknowledge it here because emotional activation allows the client to
more directly relive the traumatic event, such that any cognitive interventions are
more directly linked to specific memories of the trauma.

There are two major ways that the client can remember and, to some extent,
reexperience traumatic events during the process of treatment: (1) by describing
them in detail, and (2) by writing about them. In the first instance, the therapist
encourages the client to describe the traumatic event or events in as much verbal
detail as is tolerable, including feelings he or she experienced during and after
the victimization experience. As noted in the next chapter, this is an important
component of emotional processing. It also facilitates cognitive processing to the
extent that it includes discussion of conclusions or beliefs the survivor formed
from the experience. In response to the client’s description, the therapist
generally asks open-ended questions that are intended to make apparent any
cognitive distortions that might be present regarding blame, deservingness, or
responsibility. As the client responds to these questions, the therapist provides
support and encouragement, and, when appropriate, offers information that counters
the negative implications or self-perceptions that emerge in the client’s
responses. The client might then have responses that lead to further questions from
the therapist. Or, the topic might shift to the client’s emotional processing of
the implications of any new information, insights, or feelings that arose from the
discussion process.

The second major form of cognitive processing involves the use of “homework,”
wherein the client is asked to write about a specific topic related to the trauma,
bring it to the next session, and read it aloud in the presence of the clinician.
In this way, the client has the opportunity to continue therapeutic activities
outside of the session, including desensitization of traumatic memories (see
Chapter 8) and continued cognitive reconsideration of trauma-related assumptions
and perceptions. In addition, research suggests that the mere act of writing about
an upsetting event, especially if done on multiple occasions, can reduce
psychological distress over time (Pennebaker & Campbell, 2000). (See pages 176–177
in Chapter 8 for an example of trauma processing homework, adapted from Resick and
Schnicke, 1992.)

The goal of such activities, whether verbal or written, is to activate the client’s
memories of the traumatic event and to cognitively process them in subsequent
discussions. The initiation and maintenance of such discussions often center on
what is known as the Socratic Method: a series of gentle, often open-ended
inquiries that allow the client to progressively examine the assumptions and
interpretations he or she has made about the victimization experience.

Typical questions, in this regard, include (but are not limited to):

• “Did you have any thoughts while it was happening? What were they?”

• “Given the situation, do you think there was anything else you could have
done?”

• “So, that made you feel that you were to

blame/responsible/bad/stupid/seductive. Can we go over what happened and see what
made you think that?”

• “Did you want him/her/them to rape/beat/abuse/hurt you? Do you remember ever

wanting that?”

• “You say that you were hurt/raped/beaten because you asked for
it/wereseductive/didn’t lock the door/were out late. Can we go over the evidence
for that conclusion? Maybe it’s more complicated than that?”
• “If this happened to someone else, would you come to the same conclusions?”

• “It sounds like you believe what he/she said about that. Was he/she the kind of
person you would believe when he/she said something?”

• “Why do you think he/she did that? Did he/she get anything out of it?”

The goal here is for the client to update his or her trauma-based understanding—not
merely to incorporate the therapist’s statements about the true state of reality or
the client’s “thinking errors.” In this regard, although therapist statements about
the presumed reality of things may sometimes be helpful, much of the knowledge the
client acquires in therapy is best learned from him- or herself. By repeatedly
comparing “old” trauma-based versions of reality with newer understandings that
arise in the context of a detailed examination of past events, the client can often
revise his or her personal history—not in the sense of making things up, but by
updating assumptions and beliefs that were made under duress and were never
revisited in detail.

This approach also can be used to examine distorted beliefs about future events,
not just feelings of responsibility or self-blame. Most typically, these thoughts
involve beliefs such as:

• I am broken and will never get better/be loved/get what I want.

• The environment is dangerous and I will be hurt again.

• I am helpless to avoid additional traumas.

• People/men/women/authority figures are predatory and can’t be trusted.

• The future is hopeless.

Cognitive interventions for such trauma-related assumptions are much like those
used to address self-blame, except that they focus more on an analysis of future
outcomes. Among the general questions the therapist might ask, rephrased for better
attunement, as necessary, are the following:

• “What are the chances that something like that would happen again in the
future?”

• “What makes you believe that your assumption is/would be true?”

• “Can you think of any examples that wouldn’t fit your belief? Could there be
exceptions to the rule?” (For example, any men who probably wouldn’t rape you, any
places where you would be safe, any things you could do to avoid potential exposure
to the trauma, at least one person you can probably trust)
• “Is there any way in which you might be underestimating your abilities when you
say that?”

• “Can you think of something you might be able to do if that happened/looked

like it might happen again?”

The therapist may ask such questions, which obviously will vary from client to
client and session to session, as the description of the trauma unfolds or after
the client’s rendition is completed. We tend to favor the latter approach:
encouraging the client to describe the trauma in detail, and then following up with
questions. In doing so, the client is more able to more fully expose herself or
himself to the story, with its attendant emotional triggers, and the therapist has
a better chance of determining what the client thinks about the trauma without the
rendition being affected by therapist responses.

However accomplished, the central goal of cognitive therapy in this area is to

assist the client to more fully and accurately explore his or her beliefs or
assumptions, and the context in which they arose, without lecturing, arguing, or
labeling such beliefs as “wrong.” Instead, such cognitions should be viewed (and
reflected back to the client) as entirely understandable reactions to overwhelming
events that involved extreme anxiety and distress, incomplete information,
coercion, confusion, and, in many cases, the need for survival defenses. Trauma-
related cognitions should be treated not as the product of client error or of
inherent neurosis, but rather as initial perceptions and assumptions that require
updating in the context of safety and support. The reader is referred to Resick and
Schnicke (1992) and Chard, Weaver, and Resick (1997) for more detailed and
programmatic discussions of the cognitive processing of traumatic experiences both
conversational and written.

While addressing cognitive distortions about the event and what it means to the
client, the clinician also may encounter distortions the client has formed
regarding the meaning of symptoms he or she is experiencing. In general, these
involve beliefs that the intrusive-reliving, numbing/avoidance, and hyperarousal
components of traumatic stress represent loss of control or major psychopathology.
In the style outlined earlier for trauma-related cognitions, the therapist can
facilitate cognitive processing of these perceptions or beliefs by asking the
client—especially after some level of psychoeducation has transpired—about (1) what
might be a nonpathologizing explanation for the symptom (for example, the survival
value of hypervigilance, or the self-medicating aspects of substance abuse), (2)
whether the symptoms actually indicate psychosis or mental illness (for example,
whether flashbacks are the same thing as hallucinations, or whether it is really
“paranoid” to be fearful about trauma-reminiscent situations), and (3) whether it
is better to actively experience posttraumatic stress (especially reexperiencing)
than to “shut down” or otherwise avoid trauma memories. Each of these (and similar)
questions may stimulate lively and clinically useful conversations, the goal of
which is not for the clinician’s view to prevail, but for the client to explore the
basis for (and meaning of) his or her internal experience.

DEVELOPING A COHERENT NARRATIVE

In addition to the cognitive processing of traumatic memories, therapy can provide
broader meaning and context. Clinical experience suggests that client descriptions
of past traumatic events often become more detailed, organized, and causally
structured as they are repeatedly discussed and explored in therapy. Research (for
example, Amir, Stafford, Freshman, & Foa, 1998) indicates that such increased
coherence is directly associated with a reduction in posttraumatic symptoms.
Although it is likely that narrative coherence is a sign of clinical improvement,
it also appears that the development of an integrated version of one’s trauma has a
positive effect on recovery (Pennebaker, 1993). As the client is increasingly able
to describe chronologically and analytically what happened, and to place it in a
larger context, he or she often experiences an increased sense of perspective,
reduced feelings of chaos, and a greater sense that the universe is predictable and
orderly, if not entirely benign (Meichenbaum & Fong, 1993). Further, creating
meaning out of one’s experiences (including conclusions about cause and effect) may
provide some degree of closure, in that the experiences “make sense” and thus may
not require further rumination or preoccupation. Finally, a more coherent trauma
narrative, by virtue of its organization and complexity, may support more efficient
and complete emotional and cognitive processing (Amir et al., 1998). In contrast,
fragmented recollections of traumatic events that do not have an explicit
chronological order and do not have obvious cause-effect linkages can easily lead
to additional anxiety, insecurity, and confusion—phenomena that inhibit effective
trauma processing.

The development of a coherent narrative usually occurs naturally during effective

trauma-focused therapy. As the traumatic event (or events) is discussed
repetitively and in detail, a process sometimes referred to as context
reinstatement (Anderson & Bower, 1972) may occur. Specifically, a detailed trauma
description may increase the survivor’s access to more aspects of the memory that,
in turn, may trigger recall of additional details. For example, a client might
initially report that “he hit me on the head, and there was yelling and blood.” In
the moment of making this statement, the reference to blood might activate more
specific memories of blood on the carpet, which, in turn, might trigger additional
recollection of the location or, perhaps, the feeling of pain associated with a
scalp laceration. Further discussion might then provide the context for a
chronological sequence. For example:

Okay, he was yelling at me, saying I was lazy, and then he hit me with an ashtray,
a green one, and it cut my head. I bled all over the carpet in the living room, I
remember some part of me thinking I’d never get that stain out.

As the sequence and details of the event become clearer, there is more material to
cognitively process, and a greater sense of stability associated with “knowing what
happened.” Further, as described earlier, greater detail often provides information
that is antidotal to cognitive distortions. For example, a client might state:

I was thinking about all the weird stuff he used to say to me and my friends, like,
before he did it to me. I’m starting to get that I didn’t do anything that caused
it—he was already looking to get me.

Or, in a date rape scenario:

I just remembered, I told him to stop, when it started to get too heavy. I tried to
stop him. It’s not like I wanted it to happen. The kissing, maybe. But not the
other things.

Although a more coherent narrative often arises naturally from repeatedly

revisiting the trauma in therapy, the clinician can work to further increase the
likelihood of this happening. This generally involves gentle, nonintrusive
questions regarding the details of the trauma, and support for the client’s general
exploration of his or her thoughts and feelings regarding the event—in the same
manner described earlier for cognitive processing. In partial contrast to cognitive
processing interventions, however, narrative interventions support the development
of broader explanations and an overbridging “story” of the traumatic event, its
antecedents, and its effects. In addition to its obviously clinical effects, an
integrated version of adverse experiences may lead to a broader overall perspective
on life, and, perhaps, greater personal wisdom, as described in Chapter 4.

COGNITIVE CHANGES ARISING FROM NON-OVERWHELMING EMOTIONAL ACTIVATION

As emphasized by Foa and Rothbaum (1998), not all cognitive effects of trauma
therapy involve verbal reconsideration or “restructuring” of traumatically altered
thinking patterns—it is also possible for the survivor’s beliefs to change during
the process of remembering and processing upsetting memories during treatment.
Summarizing a cognitive component of Foa and Kozak’s (1986) emotional processing
model, Rogers and Silver (2002) note that

individuals with anxiety disorders also have erroneous beliefs about the nature of
anxiety. They tend to see anxiety as something that will persist until they escape
the feared situation, that anxiety is physically or psychologically damaging, and
that the consequences of being anxious are very aversive. (p. 45)

In the context of processing traumatic memories in therapy, the client repetitively

experiences three things: (1) anxiety that is conditioned to the trauma memory
(that is, as a conditioned emotional response, or CER), (2) the expectation that
such anxiety signals danger and/or is, itself, a dangerous state and must be
avoided, and yet (3) an absence of actual negative outcome—he or she does not
actually experience physical or psychological harm from anxiety or what it might
presage. This repetitive disparity (a technical term that is discussed in greater
detail in Chapter 8) between the expectation of anxiety as signaling danger and
yet, the subsequent experience of non-danger probably changes the expectation over
time (in Foa & Kozak’s [1986] parlance, it modifies the attendant “fear
structure”). Beyond its cognitive effects on beliefs and assumptions associated
with the specific trauma memory, the repetitive experience of feeling anxious
during trauma therapy—in the context of therapeutic safety—probably lessens the
negative valence of anxiety, per se. In many cases, this appears to mean that the
client is less anxious about anxiety; coming to see it as merely an emotion and not
necessarily as a harbinger of danger, loss of control, or psychological disability.
Viewed in this context, the interconnection between trauma processing and affect
regulation training, as described in the previous chapter, becomes clear: increased
ability to experience negative affect without the associated catastrophizing
cognitions reduces the likelihood that such emotion will be overwhelming.

COGNITIVE INTERVENTIONS AND INSIGHT

As noted earlier in this chapter, one of the major goals of cognitive interventions
is to change how the client views himself or herself, his or her prior life
experiences, and others in his or her interpersonal environment. Such cognitive
reconsideration is often equivalent to the psychodynamic notion of insight. For
example, when the client understands (has insight into the fact) that there really
wasn’t much that he or she could do in the face of one or more uncontrollable
traumatic events, self-blame for having experienced or deserved the trauma—or for
not having avoided it—is actively contradicted. Although, as noted, such newer
cognitive understanding may not have immediate salutary effects, over time (and
upon repeatedly revisiting this fact in treatment and out) the disparity between
old assumptions and perceptions versus more recent, more accurate appraisals can
serve to neutralize or “overwrite” distorted trauma-related cognitions.

In addition, a greater understanding of the past—and insight into the various ways
in which it differs from the present—may reduce the capacity of stimuli in the
current environment to trigger posttraumatic responses. For example, “realizing”
(that is, through cognitive reconsideration and/or ongoing interactions with a
benign therapist) that interpersonal closeness is not always dangerous may reduce
the amount of distrust, fear, or anger triggered by relationships in one’s adult
environment. In a sense, what would otherwise be a trigger for memories of previous
interpersonal violence can be changed. An understanding that one can be vulnerable
around some people and not be hurt means that, on average, fewer directly
reminiscent or trauma-similar stimuli are likely to be experienced during current
intimate interactions. In other words, if people, as a group, are not immediately
equated with one’s abusive parent, batterer, or rapist, close relations with people
—in general—are less likely to trigger trauma-related memories and associated
distress. Similarly, the realization (experience) that one can be anxious without
being annihilated may result in an increased sense of security and, in some cases,
better interpersonal functioning.

There are, of course, theoretical differences in how psychodynamic and cognitive

clinicians seek to change cognitive distortions. Whereas the cognitive therapist
generally works to identify irrational thinking and to supplant it with more
accurate perceptions and beliefs, the psychodynamic clinician is especially
invested in helping the client understand the original basis for such distortions.
As Goin (1997) notes, “The cognitive therapist battles the illogic with logic,
while the psychodynamic therapist searches for the logic in the illogical” (p.
308). In trauma therapy (and some forms of modern cognitive-behavioral therapy),
both phenomena ideally occur: the client is provided with opportunities to identify
prior inaccurate thoughts about self, others, and the future (that is, through
cognitive reconsideration), and is supported in finding more accurate models of
reality, but also learns the logical basis for these distortions, given the
parameters of the trauma and the client’s initial need to adapt to them. In the
latter instance, this greater understanding of the “whys” of cognitive distortion
allows a more coherent narrative of the past, its logical effects on the survivor,
and, ultimately, the greater validity of more recent (that is, less trauma-
influenced) understandings.

The similarity and confluence between the notion of “insight” and cognitive
interventions is emblematic of the hidden similarities between many supposedly
different therapeutic approaches. In this regard, most of the best therapies
provide new information and the opportunity for new learning, often in the context
of a supportive therapeutic relationship. Frequently, the issue is less what
specific treatment is involved in this process than it is how well the client’s
access to—and integration of—new information is accomplished. The heavy-handed
“cognitive” confrontation of “thinking errors” is probably as likely to be
unsuccessful as is the ill-timed or disattuned use of depth “interpretation” in
psychodynamic treatment. On the other hand, a therapeutic approach that facilitates
the client’s growing knowledge (and coherent narrative) of himself or herself, both
now and in the past, can have substantial impacts on his or her psychological
recovery.